In the House, MD season three episode “Son of Coma Guy,” House's patient, Gabe Wozniak, ask him what last words he’d like to hear from his own father. House hesitates, but answers honestly, “I’d like him to tell me that I was right; that I did the right thing.” What does it mean, to do the “right thing?” It sounds lofty and idealistic — and completely unlike what most people (think they) know of Dr. House.
Within the universe of House, MD, Dr. Gregory House (portrayed by Hugh Laurie in a consistently complex, and often brave, performance) is widely perceived by most of his colleagues (even those who respect him) to lack any sense of ethics. He’s bigoted, he doesn’t care about patients — often, he doesn’t even know their names! He’s blunt and overly harsh, refusing to suffer fools (or idiots or morons) gladly (or at all). On more than one occasion, both dean of medicine Lisa Cuddy (Lisa Edelstein) and House’s best friend James Wilson (Robert Sean Leonard) have wondered aloud if House has “even read an ethical guideline.” He’s been called many things, from “lucky” to “reckless,” “arrogant” and “preening” to “smug” and “needy.”
But House also has a reputation for integrity, according to one of his archest enemies, Edward Vogler (season one). He’s renowned as a physician and people come from far and wide (and even Cuba) to tap into his medical expertise.
Admittedly, House has done some things to warrant the less celebrated aspects of his reputation. His colleagues, hospital lawyers, and even some patients must sometimes wonder if House operates under any sort of ethical framework at all. After all, House has afflicted a coma patient with a migraine to test the efficacy of an anti-migraine drug; he has ventured into the morgue and shot a dead person in the head to perform an MRI (performing it on a live patient would have been quite deadly — and the dead guy had, explained House, donated his body to science). He has performed one physician-assisted suicide (but refused to do another, even though everyone from Wilson to his team were pushing him to do it). He has lied to the transplant committee to avoid condemning a patient to certain death, and he provoked any number of patients into physically attacking him (albeit all for a greater medical good).
“You are aware of the Hippocratic oath, right?” asks Dr. Eric Foreman in the first season episode “Damned if you Do.”
"The one that begins 'first do no harm'? Then goes on to tell us: no abortions, no seductions, and definitely no cutting of those who labor beneath the stone? Yeah, took a read once. Wasn't impressed,” House retorts scornfully (and with great irony), questioning the ethics of medicine’s standard ethical pledge.
If doctors “first do no harm,” House might argue, many of his patients would not survive, much less get needed medical attention. Drugs, diagnostic tests, medical procedures all carry with them a degree of risk, sometimes small, and sometimes great. And when patients finally get to House, who is, in a way, a medical court of last resort, they have gone through all of medicine’s conventional wisdom, all of the tests that “first do no harm.”
And the fact that House is unafraid to venture beyond that conventional wisdom (and conventional medical ethics) allows him to save patients that other doctors would hesitate to even see, much less treat. “We’re not a lot of doctors. We’ll save a lot more patients than the guy down the street,” House explains to Foreman after losing a patient by missing a simple (but oddly presented) staph infection. “But a few of the ones he’d save by doing what everyone else does, we will lose.”
But this type of medicine is not for everybody. When Foreman resigns at the end of “Family,” he tells House, “You'll save more people than I will. But I'll settle for killing less.” But the two are not mutually exclusive.
Who has the moral high ground? The doctor who refuses to go beyond the conventions and rules of medicine, allowing a patient to die because “there was nothing more we could do?” as Foreman argues to Cuddy at the end of season two’s “Deception?” Or a doctor like House, who ignores medical conventions and ethics, only to save that same patient’s life?
House’s medical fearlessness combined with a brilliant mind, a gift for observation, and open-mindedness make him Cuddy’s “ace in the hole,” and, she believes that he is “her best doctor.” But even she has been known to suspect his motives — and his ethics.
In the season three premiere “Meaning,” when House returns to work after going through a radical pain management treatment, he takes on a paralyzed patient simply to “help him,” perhaps alleviate his pain. This, Wilson and Cuddy believe, is a good, albeit strange, thing for House to be doing, motivated by a hallucination experienced after he was shot in “No Reason.”
But when House perceives that the patient may actually have a rare condition that he can “cure,” enabling the patient to walk, talk, and even have sex with his wife, Cuddy and Wilson immediately suspect him of exploiting the patient and his family for his own personal amusement. “If I thought for a second you wanted to help him, you'd have carte blanche. You're doing this because it's fun,” Cuddy admonishes, despite House’s protestations to the contrary. As it turns out (as it often does) House is right, and the patient is, indeed, cured. (Which, ironically enough, leads Wilson and Cuddy to some highly unethical behavior of their own — towards House.)
But more often than not, Cuddy and Wilson excuse (what they view as) House’s breeches of ethics and protocol for his success rate — for the lives that would be lost but for House’s intervention, whatever his motives. But not everyone agrees that House’s success rate, his ability to cure hopeless cases, excuses his constant flouting of medicine’s vaunted ethical framework.
In season two’s “Deception,” Foreman accuses House of being “an anarchist. All he stands for is the right for everyone to grab whatever they want, whenever they want.” If everyone practiced medicine the way House does, Foreman warns, there will be more patient deaths, not fewer. And he’d be right. But this is House we’re talking about. Not “every” doctor. Right?
House’s reputation as a medical anarchist, willing (sometimes too willing) to break the rules, goes beyond the walls of Princeton Plainsboro Teaching Hospital. In the season three episode “Informed Consent,” Dr. Ezra Powell, a renowned physician/researcher (and someone whom House greatly admires) comes to House with heart and lung symptoms after collapsing in his lab. Powell, in a great deal of pain, admits that he came to House specifically because he “figured (he’d) have the guts to do what had to be done, if it came to that. “
But Powell has misjudged House’s ethical flexibility. “We're nowhere near that,” House responds, asking Powell for more time to diagnose his condition. Wilson, too, wonders why House is reluctant to give Powell a syringe-full of morphine and end his life. “You’ve done it before. Plenty of times,” Wilson reminds him. But, explains House, only “to patients that I knew were terminal.”
Ultimately diagnosed with a fatal disease, one that will result in a slow and painful death, Powell mysteriously and suddenly dies in the middle of the night. Cuddy confronts House in his office to ask him if he knows anything about this suspicious death.
House asks in return: “If I did, would you want to know that?” It's a question to which they both know the answer. It is actually Cameron who carries out the deed, earning House’s undying respect. “I’m proud of you,” he tells Cameron as she mourns her actions (and perhaps the loss of her medical innocence) in the hospital chapel. I get the impression from that brief scene that this is a place House has been before, and with no less anguish than Cameron’s.
House is not opposed to ending the life of a suffering patient, as we learn in “Son of Coma Guy.” In that episode House helps Gabe, condemned to life as a vegetable, commit suicide in order to save the life of his son. As House sits vigil outside Gabe’s hotel room, waiting for him to die, you can see the toll this decision has taken on him. And when Cuddy confronts him about it in a scene that parallels their scene in “Informed Consent,” there is no doubt about what happened and why.
House’s actions were neither ethical nor legal in any conventional sense, and it’s clearly not something he’s done cavalierly. But was it not “the right thing” to do, given the circumstances, something that drives so much of House’s actions, ethical or not?
House’s actions often cause others to prejudge him — and to misjudge him. Foreman quits at the end of season three, no longer willing to learn from House or practice his style of medicine; unwilling to “become” House. In “Resignation,” Cuddy shows Foreman the good that House does, as they look in on a young woman who would have died except for House’s refusal to give up on her, even after he had diagnosed her as terminal. But Foreman’s not buying. “Don't tell me I'm better than him, don't tell me to take the good, leave the bad…” he says, misunderstanding the lesson Cuddy’s trying to impart.
She is telling him instead that there are many worse things to be than House. Unlike Wilson and Cuddy (and often Cameron and Chase), the judgmental Foreman refuses to see beyond House’s surface to what lies beneath. “House is evil,” Foreman finally concludes, missing the point.
Wilson practically implores House in the season three finale to finally show himself. “Foreman’s quitting because he doesn’t want to be what he thinks you are.” There are miles between those two polar locations. But House is unwilling to defend himself to Foreman; why should he?
In season four, mis-perceptions of House’s ethics and ethical boundaries cause three candidates to lose their jobs. In “Whatever it Takes,” Dr. Travis Brennan (otherwise known as “Dr. Grumpy”) overtly exploits a patient under the team’s care in order to simulate polio while House is off playing secret agent with the CIA. He does this, claims Brennan, for purely altruistic reasons: to secure funding for an experimental polio treatment. Discovering the deception, House orders Brennan to pack up his things and get out; that there is no place for him on the team. “What do you care if I faked a lab test if it saves a few thousand lives? I did what I had to do. Isn't that what you hired us for?” ask Brennan, pleading for his job. Needless to say, Brennan is a goner.
Amber Volakis (“Cutthroat Bitch”) also loses her job although House admits she “plays the game better than anybody else. But for the wrong reasons.” She plays to win; to be right. She fails to understand that losing, being wrong, and making adjustments are part of House’s collegial process. She is a bit too “every person for herself” for House’s practice.
And even that lovable “ridiculously old fraud” misperceives that House is such a rebel that he wouldn’t care that about trivial matters like medical degrees. “I heard you break the rules. I thought you’d break one for me,” he explained after House discovers that although he’s audited medical school classes for years, he lacks an actual degree. And while House appreciates “ROF’s” wisdom and creative thinking, he refuses to bring him on as a physician.
I’m not saying that House is a “good guy.” He often isn’t. He’s abrupt and abrasive, rude and uncompromising. Does House cross lines that he shouldn’t? Yes. Has he done things medically that have been not necessarily been best for the patient? On several occasions, yes. And those should not be dismissed. But House has a very defined sense of medicine, of ethics and medical justice that goes beyond much of common medical practice. And over four seasons, we’ve seen fragments of it in nearly every episode.
And whether House admits it or not, his experiences, both his own personal tragedies and those things he’s experienced as a physician, have had a profound effect on him, and on how he views the practice of medicine. That experience makes him skeptical of conventional medical wisdom, and of what he sees as hypocrisy in medicine. He believes that blind adherence to standards of medical practice often comes into conflict with patient care.
In the season one episode “Socratic Method,” House argues with Cuddy about the ethics of temporarily shrinking a tumor, to put it within the surgical guidelines. Cuddy argues that medical guidelines have a purpose that should not be disregarded.
“I know – to save lives. Specifically doctors’ lives, and not just their lives but their lifestyles. Wouldn’t wanna operate on anyone really sick – they might die and spoil our stats… I got all focused on her right to live, and forgot. You do what you think is right.”
Is House right to temporarily shrink the tumor to trick the surgeon into operating on it? Or should he have let her die because the tumor fell ten percent beyond the surgical guidelines? Wilson, the oncologist, agrees with House, and ultimately so does Cuddy. But it’s the sort of ethical dilemma that House pushes all of the time.
In the season one episode “Control,” House lies to the transplant committee to secure a heart for a bulimic patient, one he could not condemn to death. Was House simply being the best advocate possible for his patient, or was he, by his actions, condemning someone else to death to benefit a less worthy patient?
Is following the rules, strictly adhering to ethical guidelines and standards of practice, the same as “doing the right thing?” Who gets to decide? Is there a standard or ethical framework that begins to explain House’s unique way of practicing medicine?
Stay tuned for part two. And many thanks and all credit to the transcript mavens at the Clinic Duty Live Journal.